Justin Oakley

Practical virtue ethics: healthcare whistleblowing and portable digital technology

Medical school curricula and postgraduate education programmes expend considerable resources teaching medical ethics. Simultaneously, whistleblowers’ agitation continues, at great personal cost, to prompt major intrainstitutional and public inquiries that reveal problems with the application of medical ethics at particular clinical “coalfaces”. Virtue ethics, emphasising techniques promoting an agent’s character and instructing their conscience, has become a significant mode of discourse in modern medical ethics. Healthcare whistleblowers, whose complaints are reasonable, made in good faith, in the public interest, and not vexatious, we argue, are practising those obligations of professional conscience foundational to virtue based medical ethics. Yet, little extant virtue ethics scholarship seriously considers the theoretical foundations of healthcare whistleblowing. The authors examine whether healthcare whistleblowing should be considered central to any medical ethics emphasising professional virtues and conscience. They consider possible causes for the paucity of professional or academic interest in this area and examine the counterinfluence of a continuing historical tradition of guild mentality professionalism that routinely places relationships with colleagues ahead of patient safety. Finally, it is proposed that a virtue based ethos of medical professionalism, exhibiting transparency and sincerity with regard to achieving uniform quality and safety of health care, may be facilitated by introducing a technological imperative using portable computing devices. Their use by trainees, focused on ethical competence, provides the practical face of virtue ethics in medical education and practice. Indeed, it assists in transforming the professional conscience of whistleblowing into a practical, virtue based culture of self reporting and personal development.

Cardiac surgeon report cards, referral for cardiac surgery, and the ethical responsibilities of cardiologists.

Public reporting of clinical outcomes data is but one response to calls for increasing transparency in health care. Cardiac surgical operations are among the most commonly performed complex operative procedures. Risk-adjusted cardiac surgery mortality rate data for individual cardiac surgeons are currently available for >25% of the U.S. population as well as for Great Britain and Ireland. Although cardiologists are the primary source of referral of patients for cardiac surgery, surveys of cardiologists and analysis of market share data indicate this information is not being used to refer to cardiac surgeons with the lowest mortality rates. We review the ethical principles that should obligate cardiologists to discuss and use outcomes data, when available, in selecting cardiac surgeons to whom they refer their patients.

Public disclosure of surgeon-specific report cards: current status of the debate.

Clinical report cards are at the centre of an escalating debate on ways in which the performance of hospitals and individual doctors can be monitored. Report cards are a method of publishing outcome data that can be focused on a particular hospital, clinical unit, or an individual doctor. Following the public disclosure of results of individual cardiac surgeons in New York State, USA, and the recent Inquiry into paediatric cardiac surgical deaths at the Bristol Royal Infirmary, UK, there is increasing focus on the possibility of the introduction of report cards in Australia. At present, the increasing momentum and implementation of report cards is focused squarely on surgeons, and particularly on cardiac surgeons. This review outlines the events in the USA and UK and looks into the possible impact of the introduction of report cards in Australia.

Ethical and scientific considerations for patient enrollment into concurrent clinical trials

Researchers and institutional review boards often consider it inappropriate for patients to be asked to consent to more than one study despite there being no regulatory prohibition on co-enrollment in most countries. There are however ethical, safety, statistical, and practical considerations relevant to co-enrollment, particularly in surgery and perioperative medicine, but co-enrollment can be done if such concerns can be resolved. Preventing eligible patients from co-enrolling in studies which they would authentically value participating in, and whose material risks and benefits they understand, violates their autonomy - and thus contravenes a fundamental principle of research ethics. Statistical issues must be considered but can be addressed. In most cases each trial can be analyzed separately and validly using standard intention to treat principles; selection and other biases can be avoided if enrollment into the second trial is not dependent upon randomized treatment in the first trial; and valid interaction analyses can be performed for each trial by considering the patient’s status in the other trial at the time of randomization in the index trial. Clinical research with a potential to inform and improve clinical practice is valuable and should be supported. The ethical, safety, statistical, and practical aspects of co-enrollment can be managed, providing greater opportunity for research-led improvements in clinical practice.

Consequentialism, Moral Responsibility, and the Intention/ Foresight Distinction

In many recent discussions of the morality of actions where both good and bad consequences foreseeably ensue, the moral significance of the distinction between intended and foreseen consequences is rejected. This distinction is thought to bear on the moral status of actions by those who support the Doctrine of Double Effect (DDE). According to this doctrine, roughly speaking, to perform an action intending to bring about a particular bad effect as a means to some commensurate good end is impermissible, while performing an action where one intends only this good end and merely foresees the bad as an unintended sideeffect may be permissible. Consequentialists argue that this is a distinction which makes no moral difference to the evaluation of the initial act in the two cases, given that the overall consequences are the same in each case. In this paper we aim to show that a standard consequentialist line of argument against the moral relevance of the intention/foresight distinction fails. Consequentialists commonly reject the moral relevance of this distinction on the grounds that there is no asymmetry in moral responsibility between intending and foreseeing evil. We argue that even if this claim about moral responsibility is correct, it does not entail, as many Consequentialists believe, that there is no moral asymmetry between acts of intended and foreseen evil. We go on to argue that those consequentialists who do concede the moral relevance of the intention/foresight distinction at the level of agent evaluations cannot consistently make such a concession, and that such a position is in any case untenable, because it entails a complete severance of important conceptual connections between act and agent evaluations.

Good medical ethics, from the inside out—and back again

I argue here that good medical ethics requires an empirically-informed moral psychology of medical virtue along with sound action-guiding prescriptions for virtuous medical practice. After distinguishing between three levels of justification, I indicate how medical virtue ethics can draw constructively on relevant empirical research in developing feasible and realistic aspirational standards for doctors, and in evaluating how policymakers can support doctors in acting on the virtues that doctors agreed to be guided by when they joined the profession.

Ethics of implicit persuasion in pharmaceutical advertising

Direct to Consumer Advertising of Prescription Pharmaceuticals (DTCA) is a controversial practice permitted only in the United States and New Zealand. Central to why all other nations ban DTCA is concern about its capacity to impart complete, balanced, and accurate information that guides effective consumer decisions. Yet the debate has, thus far, paid scant attention to how implicit or unconscious persuasion in DTCA might influence consumer attitudes toward advertised drugs. In this chapter, one means of implicit persuasion, evaluative conditioning, is argued to have deleterious effects on the autonomous agency

Can self-preservation be virtuous in disaster situations?

Ordinary moral rules and virtues can be found seriously inadequate in circumstances where natural catastrophes afflict large numbers of people. Satoshi Kodama provides a strong defence of the rule of tsunami-tendenko being invoked as an evacuation policy in these exceptional situations, such as that facing many people in the Tōhoku region of Japan during the severe earthquake and subsequent tsunami there on 11 March 2011.1 As Kodama explains, tsunami-tendenko tells a person in such situations to prioritise self-preservation over attempting to help others, and people living in earthquake-prone and tsunami-prone areas have learned from past experience that acting on such a rule is likely to save more lives overall than is acting on a policy of searching for and attempting to help others escape the disaster. Tsunami-tendenko seems to be a reasonable general principle for people to follow in such exceptional circumstances, particularly where disasters strike suddenly, and the resulting chaos can make efforts to locate others not only extremely difficult but in some cases suicidal. Kodama provides plausible indirect consequentialist arguments for this principle to be used in these dramatic situations. This ethical demand to …

Practitioner Courage and Ethical Health Care Environments

In this issue of the Hastings Center Report, Ann Hamric, John Arras, and Margaret Mohrmann highlight how contemporary accounts of the virtue of courage in health care often gloss over deeper problems in the underlying health care systems themselves. They express particular concerns about the appropriateness and personal costs of exhortations to health professionals to take courageous action in circumstances where this is “required only because of unethical institutional structures” (p. 39). They offer valuable points that are not adequately recognized in discussions of courage as a professional virtue in health care practice. The call for more judicious appeals to health professionals to exercise courage in health care practice should clearly be heeded. A sole reliance on practitioner courage for exposing unethical workplace practices would be misguided. Nevertheless, there is still a legitimate place for encouraging health professionals to develop and act on courage.

Surgeon Report Cards, Clinical Realities, and the Quality of Patient Care

In this article, I respond to Alan Henderson’s critique of the quality of care argument for surgeon report cards. I discuss some significant US and UK studies demonstrating that surgeon report cards improve clinical outcomes. I also indicate that surgeon report cards are in any case supported by other important ethical arguments, such as arguments from surgeons’ professional accountability obligations, and from patients’ entitlements to be informed about the risks of surgery upon them.